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A woman who is Rh-negative is pregnant with her first child, and her husband is Rh positive. During her 12-week prenatal visit, she tells the nurse that she has been told that this is dangerous. What should the nurse tell her?
- A. That no treatment is necessary
- B. That an exchange transfusion will be necessary at birth
- C. That no treatment is available until the infant is born
- D. That administration of Rh immunoglobulin is indicated at 26 to 28 weeks of gestation
Correct Answer: D
Rationale: The goal is to prevent isoimmunization. If the mother has not been previously exposed to the Rh-negative antigen, Rh immunoglobulin (RhIg) is administered at 26 to 28 weeks of gestation and again within 72 hours of birth. The intramuscular administration of RhIg has virtually eliminated hemolytic disease of the infant secondary to the Rh factor. Unless other problems coexist, the newborn will not require transfusions at birth.
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Which intervention may decrease the incidence of physiologic jaundice in a healthy full-term infant?
- A. Institute early and frequent feedings.
- B. Bathe newborn when the axillary temperature is 36.3 C (97.5 F).
- C. Place the newborns crib near a window for exposure to sunlight.
- D. Suggest that the mother initiate breastfeeding when the danger of jaundice has passed.
Correct Answer: A
Rationale: Physiologic jaundice is caused by the immature hepatic function of the newborns liver coupled with the increased load from red blood cell hemolysis. The excess bilirubin from the destroyed red blood cells cannot be excreted from the body. Feeding stimulates peristalsis and produces more rapid passage of meconium. Bathing does not affect physiologic jaundice. Placing the newborns crib near a window for exposure to sunlight is not a treatment of physiologic jaundice. Colostrum is a natural cathartic that facilitates meconium excavation.
The nurse is caring for a breastfed full-term infant who was born after an uneventful pregnancy and delivery. The infants blood glucose level is 36 mg/dL. Which action should the nurse implement?
- A. Bring the infant to the mother and initiate breastfeeding.
- B. Place a nasogastric tube and administer 5% dextrose water.
- C. Start a peripheral intravenous line and administer 10% dextrose.
- D. Monitor the infant in the nursery and obtain a blood glucose level in 4 hours.
Correct Answer: A
Rationale: A full-term infant born after an uncomplicated pregnancy and delivery who is borderline hypoglycemic, as indicated by a blood glucose level of 36 mg/dL, and who is clinically asymptomatic should probably reestablish normoglycemia with early institution of breast or bottle feeding. The newborn does not require a nasogastric tube and 5% dextrose water or a peripheral intravenous line with 10% dextrose because the blood glucose level is only borderline. The infant does need to be monitored, but breastfeeding should be started and the blood glucose level checked in 1 to 2 hours.
When should the nurse expect breastfeeding-associated jaundice to first appear in a normal infant?
- A. 2 to 12 hours
- B. 12 to 24 hours
- C. 2 to 4 days
- D. After the fifth day
Correct Answer: C
Rationale: Breastfeeding-associated jaundice is caused by decreased milk intake related to decreased caloric and fluid intake by the infant before the mothers milk is well established. Fasting is associated with decreased hepatic clearance of bilirubin. Zero to 24 hours is too soon; jaundice within the first 24 hours is associated with hemolytic disease of the newborn. After the fifth day is too late. Jaundice associated with breastfeeding begins earlier because of decreased breast milk intake.
A pregnant client asks the nurse to explain the meaning of cephalopelvic disproportion. Which explanation should the nurse give to the client?
- A. It means a large for gestational age fetus.
- B. It is the narrow opening between the ischial spines.
- C. There is an uneven size between the fetus presenting part and the pelvis.
- D. The shape of the pelvis is an android shape and is unfavorable for vaginal delivery.
Correct Answer: C
Rationale: Cephalopelvic disproportion means a disproportion (or uneven size) between the fetus presenting part and the maternal pelvis. It does not mean a large for gestational age fetus or that the pelvis is an android shape. The narrow opening between the ischial spines is called the transverse measurement.
A newborn has been diagnosed with brachial nerve paralysis. The nurse should assist the breastfeeding mother to use which hold or position during feeding?
- A. Reclining
- B. The cradle hold
- C. The football hold
- D. The cross-over hold
Correct Answer: C
Rationale: In brachial nerve paralysis, the affected arm is gently immobilized on the upper abdomen. Tucking the newborn under the arm (football hold) puts less pressure on the newborns affected extremity. The other positions place the newborns body next to the mothers and can cause pressure on the affected arm.